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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 49-52

Bosworth screw for acromioclavicular joint injuries: Indications and operative outcomes


Department of Orthopaedics, B. J. Medical College, Civil Hospital, Ahmedabad, Gujarat, India

Date of Submission12-Dec-2017
Date of Acceptance29-Jan-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Kirtan Vijay Tankshali
87, Goyal Park Row-Houses, Judges Bungalow Road, Vastrapur, Ahmedabad - 380 015, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_69_17

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  Abstract 


Introduction: Acromioclavicular joint is a biomechanically complex joint, isolated injuries of which are rare. Complex classification system (Rockwood) and no universally approved guidelines for the treatment with the ever evolving surgical techniques pose further challenge for the treatment of the condition. We have in our current study, assessed operative outcomes of Bosworth screw fixation for AC joint injuries and the role of occupation in deciding treatment regimen and predict operative outcomes. Materials and Methods: This is a prospective cohort study of 11 patients having isolated AC joint injury classified as grade II or higher according to Rockwood classification treated with Bosworth screw fixation at high patient turnover tertiary care centre. Results: AC joint injuries are more common in males and RTA accounts for the most of the injuries. There is significant difference in outcomes of operative fixation between high demanding and low demanding occupation as evaluated by constant shoulder score (P < 0.01). Operative treatment in failed conservative treatment of type II/III injuries yields better constant score. The earlier the treatment, the earlier the vocational rehabilitation especially in high demanding occupation. Conclusion: Occupation should be considered in making treatment choice of AC joint injuries and not only type of injury. Bosworth technique of fixation is old but cost effective, easily reproducible, less time consuming technique with smaller learning curve and should be considered in all type V injuries and in patients with type II/III injuries involved in high demanding occupation.

Keywords: Acromioclavicular joint injuries, Bosworth screw, high-demanding occupation, Rockwood classification


How to cite this article:
Tankshali KV, Patel ZM, Acharya HP. Bosworth screw for acromioclavicular joint injuries: Indications and operative outcomes. J Orthop Traumatol Rehabil 2020;12:49-52

How to cite this URL:
Tankshali KV, Patel ZM, Acharya HP. Bosworth screw for acromioclavicular joint injuries: Indications and operative outcomes. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Sep 21];12:49-52. Available from: http://www.jotr.in/text.asp?2020/12/1/49/287723




  Introduction Top


Acromioclavicular (AC) joint is a plane synovial/diarthrodial joint between acromion process of the scapula and lateral end of the clavicle bone.[1] The joint is an important link between the appendicular skeleton (upper limb) and axial skeleton. Furthermore, the joint is stabilized by structures such as joint capsule, AC ligament, deltotrapezial fascia, and coracoclavicular (CC) ligaments (which play a major role in weight transmission). Multiple ligaments acting on single joint make biomechanics of the joint more complex. Optimal joint functioning is desired for pain-free upper limb function and normal day-to-day weight-lifting activities. Injury to the joint is rare but remains an entity with a complex classification system with no emphasis on the role of occupation, no standard treatment protocol, no established guidelines for the choice of ideal surgical procedure. Advances described for the treatment options for these injuries, such as anatomical CC reconstruction (ACCR) or arthroscopic repair, are more time-consuming, not easily reproducible, and require longer learning curves. Besides, cost–benefit analysis has also to be kept in mind as these newer procedures are costlier as compared to the conventional method. We have, in our present study, evaluated the role of occupation in decision-making of treatment for these injuries, especially Rockwood Types 2 and 3 injuries (for which there still is no consensus regarding the treatment recommendations) and assessed the operative outcomes of Bosworth screw fixation for AC joint injuries.


  Materials and Methodology Top


This is a prospective cohort study of the 11 AC joint injuries operated at a tertiary care center between January 1, 2014 and May 31, 2016, with Bosworth screw fixation. Patients with isolated injury of Rockwood Type II to VI who were willing to get operated were included in our study. Patients of polytrauma having associated AC joint injury and patient giving negative consent for the surgery were excluded from the study. Polytrauma patients were specifically excluded so as to remove any confounding factor affecting the treatment outcome of the procedure. Type I injury was excluded as standard treatment protocol of such injuries is conservative option only with skillful neglect. Although standard treatment protocol for Type 2 injury is conservative treatment, we had patients with failed conservative treatment for these injuries and were included in our study.

As per our standard protocol, all the patients underwent radiographical investigations in the form of anteroposterior, axillary radiograph of the shoulder joint with clavicle, Zanca view of normal and affected side, whenever possible in a single plate for better comparison. Patients were classified under high-demanding and low-demanding occupations depending upon the involvement of overhead activities and heavyweight lifting in day-to-day life. All the patients enrolled in our study were operated by Bosworth screw fixation[2],[3] and followed up to a minimum period of 1 year postoperatively. The above-mentioned radiographic views were obtained at Each follow-up visit with evaluation of constant score, and outcomes were analyzed.

All the patients were operated under general anesthesia in modified beachchair position by using cannulated cancellous screw (CCS) of 4.0 mm size with washer. There was no added cost burden on patient or hospital system in terms of instrumentation as CCS screws along with washer and general surgical equipment are all that is required to perform the surgery and are readily available at our center.

Observation and analysis

All the 11 patients enrolled in our study were male with their age ranging from 22 to 55 years and the average age is 34 years. The most common mode of trauma was road traffic accident (RTA) in 7 out of 11 patients. Other modes include injury while playing sports (2/11) and fall down while doing manual labor (2/11). Only 6 out of 11 patients presented to us in acute setting, i.e., within 3 days of injury. The presentation time of other five patients ranged from 7 days to 90 days. The chief complaint at the time of presentation was pain or instability at the AC joint in 9/11 patients, and two patients came to us for cosmetic purpose. Five out of 11 patients were treated conservatively elsewhere before presenting to us. The distribution of patients according to Rockwood classification is shown in [Table 1].[4] No patient in our study had Type IV/VI injury, indicating rarity of both types.
Table 1: Distribution of patients according to injury type

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The time to return to daily activities ranged from 30 to 50 days and time for vocational rehabilitation ranged from 1.5 to 6 months. Ten out of 11 patients achieved vocational rehabilitation in our study. Constant score at the end of 1-year follow-up ranged from 69 to 91 [Figure 1]. Major limitations noted in our study were reduced strength for abduction and restriction of movement at terminal abduction (>150°). Implant impingement was observed in 2 out of 11 patients, persistent pain with restricted range of motion was noted in one patient, and recurrence of cosmetic deformity was noted in one patient which occurred following implant removal due to impingement.
Figure 1: Constant shoulder score follow-up at 1 year

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  Discussion Top


As observed in our study, AC joint injuries are more common in males (100% in our study) and in third and fourth decades of life (nine patients). The most common mode of trauma was RTA in our study (7/11). Sports-related injury was found only in two patients, which is contradictory to the various studies published in literature.[5],[6] Clear mechanism of injury could not be established as majority of the RTA victims did not remember the event in the reproducible manner, but majority of them had direct trauma to the joint or fall on outstretched hand. Among other modes of trauma, direct impact on AC joint (two patients) – direct fall while performing heavy labor duties and excessive force on affected side's upper extremity – while playing sports (Kabaddi in both cases) accounted for equal incidences. There was no high-risk occupation noted in our study which would predispose the patients to this type of injury.

Six patients presented to us in acute setting, i.e., within 3 days. The rest after at least 7 days of injury, with range for presentation time, is 7–90 days. The reason for late presentation was failure of conservative treatment to reduce pain and cosmetic deformity with relatively preserved range of motion. Even in the setting of acute trauma, the major presenting complaint was pain or instability at the AC joint with five out of six patients performing abduction of up to 90° with pain only at terminal movements. Eight out of 11 patients could reduce the joint manually with pressure and elevation of the arm but complained of instability upon relieving the pressure/inability to maintain reduction.

Out of 11, two patients had Rockwood Type II injury. Both the patients were given conservative treatment trial previously for 8 weeks, and persistent pain was the chief complaint at the time of admission. Rockwood Type II injury has fair consensus regarding conservative treatment, but we encountered these two patients who had failure of conservative treatment. Occupation of both the patients demanded routine overhead activities which might be the reason for the failure of conservative treatment. Five patients had Rockwood Type III injury, out of which three patients were given conservative treatment trial previously elsewhere which had failed to relieve symptoms, whereas two patients presented to us within 3 days of injury. None of the late presenters had SICK scapula syndrome.[1] Four patients had Rockwood Type V injury, all of which presented to us within 3 days of injury and were fixed in the acute sitting. No patients of Type IV or VI injuries presented to us during our study period, suggesting rarity of these types.[6],[7]

All the patients after necessary preoperative workup were operated with Bosworth screw fixation [Figure 2] under general anesthesia and in modified beachchair position. The average operative time was 25 min in our study. None of the patients required postoperative blood transfusion as there was minimal blood loss. Postoperatively, Zanca views were obtained for bilateral AC joints and CC distance of both the sides compared. All the patients had CC distance within 10% of the normal side. The average postoperative hospital stay was 1 day in our study. All the patients were guarded in shoulder arm immobilizer up to 1.5 months to allow for soft-tissue healing and to avoid implant backout which is a known complication of this type of fixation. Wrist and finger mobilization was started on the same day, and guarded passive mobilization at the shoulder was started on postoperative day 15 at the time of stitch removal. Patients were followed up to 1 year postoperatively. The outcomes were analyzed using constant shoulder score which includes subjective and objective criteria such as pain, activities of daily living (sleep, work, and recreation), strength, and range of motion (ROM). Constant scores ranged from 69 to 91 at the end of 1-year follow-up.[8]
Figure 2: Pre- and postoperative anteroposterior radiograph of acromioclavicular joint injury

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Major disability observed in our study was terminal restriction of abduction (>150°) and the inability to lift the heavyweight (>15 kg). There was no correlation noted between the type of injury and constant score. However, occupation had definite effect on the outcome. Failure of conservative treatment was noted in patients who were involved in heavyweight lifting or overhead abduction activities, i.e., “high-demanding occupation.” Occupation also had effect on vocational rehabilitation, with patients involved in high-demanding occupation taking around 6 months for vocational rehabilitation as compared to low-demanding occupation which on average required 2 months of time for vocational rehabilitation. Thus, the role of occupation in treatment and rehabilitation of these injuries need to be emphasized. Comparing constant scores of high-demanding (74.8) with low-demanding occupation (85.67) [Figure 2], independent t-test yielded a t-score of 4.68 with P < 0.0011 meaning, thereby constant score was significantly lower in individuals involved in high-demanding occupation as compared to low-demanding occupation at the final follow-up. High-demanding occupation individuals with Type II injury may be considered for operative treatment in the initial stage only as there also are high chances of failure with conservative management, and operative treatment provides better vocational rehabilitation. Five out of11 patients of our study presented after failed conservative treatment and three of them had Type 2 injuries, two of them had Type III. Except for Type V injury, all the patients were involved in high-demanding occupation, and their shoulder score improved from an average of 43.75–73.25 with the Bosworth technique as analyzed at the 1-year follow-up. P values and significance are not commented due to only four patients, but there clearly is improvement of scale 30 on average in the constant scores. Thus, earlier intervention should be offered even in Type 2 injuries in high-demanding individuals.

The complication of implant impingement was observed in two patients which required implant removal at the end of 1 year. The recurrence of cosmetic deformity was observed in one patient after implant removal for impingement, but the patient had pain free and full ROM, so no further intervention was planned. One patient had persistent pain even at the end of 1 year with restricted ROM. The patient was manual laborer and did not follow standard physiotherapy protocol and started work at 45 days including painful overhead abduction with heavyweight carrying on the head. Upon follow-up radiograph at 1 year, CC distance was found to be 30% more than normal which might be the reason for persistent pain. The same patient could not achieve vocational rehabilitation for preinjury occupation and had to change the occupation later on. Other than these two patients, no patients had increased CC distance of more than 25% as compared to the normal side. There was no coracoid or clavicular fracture observed in our study.[3],[6],[9]

Due to high patient load at our tertiary care center, it was not possible to offer ACCR/arthroscopic reconstruction to all the patients. Our recommendation of operating Type II injuries in high-demanding occupation is based on small number of patients, which requires larger multicentric studies to support the recommendation. The definition of high-demanding occupation is based on two criteria of overhead abduction and heavyweight lifting which requires further validation. We recommend adding occupation to the classification system to help decide the treatment modality (operative vs. conservative) and predict prognosis in a better way. However, how much emphasis should be given to these occupation criteria needs to be standardized and for that larger demographic studies are required.


  Conclusion Top


AC joint injuries are of rare occurrence and are common in males. Injury occurs mainly due to direct trauma to the joint caused by RTAs. Occupation has a definite role in the prognosis of the injury and should be added in any classification system to recommend treatment modality. According to our study, Types II, III injuries in high-demanding occupation and Type V injuries should preferably be operated as it has better outcomes with earlier rehabilitation as compared to nonoperative treatment. Bosworth technique is a highly cost-effective, less time-consuming method with excellent outcomes and can be used for any type of AC joint injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rockwood CA Jr., Green DP, Bucholz RW, Heckman JD. Fractures in Adults. 6th to 8th ed. Wolters Kluwer, Philaldelphia; 2015.  Back to cited text no. 1
    
2.
Bosworth BM. Acromioclavicular separation: New method of repair. Surg Gynecol Obstet 1941;73:866-71.  Back to cited text no. 2
    
3.
Bosworth BM. Acromioclavicular dislocation: End-results of screw suspension treatment. Ann Surg 1948;127:98-111.  Back to cited text no. 3
    
4.
Rockwood CA. Injuries to the acromio-clavicular joint. In: Green R, editors. Fractures in Adults. Philadelphia: JB Lippincott; 1984. p. 680-910.  Back to cited text no. 4
    
5.
Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med 2005;33:1142-6.  Back to cited text no. 5
    
6.
Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ. Acromioclavicular joint injuries: Diagnosis and management. J Am Acad Orthop Surg 2009;17:207-19.  Back to cited text no. 6
    
7.
Joukainen A, Kröger H, Niemitukia L, Mäkelä EA, Väätäinen U. Results of operative and nonoperative treatment of Rockwood types III and V acromioclavicular joint dislocation: A prospective, randomized trial with an 18- to 20-year follow-up. Orthop J Sports Med 2014;2.  Back to cited text no. 7
    
8.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;(214):160-4.  Back to cited text no. 8
    
9.
Warth RJ, Martetschläger F, Gaskill TR, Millett PJ. Acromioclavicular joint separations. Curr Rev Musculoskelet Med 2013;6:71-8.  Back to cited text no. 9
    


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